Medical-grade Honey as an Alternative to Surgery: A Case Series

Introduction. Modern wound management continues to present new challenges. Many patients elect to forego operative debridement secondary to high risk, fear, cost concerns, and personal ideologies on healing. Although operative debridement has long been a tenet of proper wound care, alternative innovative approaches to wound management must be considered. Objective. This case series describes the successful outcomes of 12 patients with dissimilar wounds who were managed with medical-grade honey (active Leptospermum honey [ALH]) as an alternative to surgery. Materials and Methods. A case series was identified from clinical experience, chart review, and photographic documentation of all patients evaluated by the acute wound care service. To be included, patients had to decline the recommendation of operative debridement or skin grafting, utilize ALH as an alternative to surgery, and have regular follow-up visits. Results. Twelve patients with complex wounds were identified and included in this case series. Five patients were considered high risk for surgery due to comorbidities. Seven patients were at low risk for surgery but desired to avoid operative procedures. The use of ALH facilitated autolytic debridement and healing without surgery or hospital readmission. Conclusions. The properties of ALH include autolytic debridement, bacterial growth inhibition, anti-inflammatory mediation, and cytokine release, making it a viable option for wound management for patients with contraindications to surgery. However, surgical debridement should remain a tenet of wound care in appropriate patients.

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In the setting of an aging population with increasing incidence of comorbidities, operative intervention is becoming more challenging. In low-risk patients, surgical intervention may be declined secondary to fear, cost, or personal beliefs on healing. The increasing occurrence of complex wounds and infections resistant to antibiotic therapy necessitates the development of wound care treatment alternatives.

The use of honey in wound care has been documented in the literature since the early 20th century.¹ Its use dwindled with the advent of antibiotics in the 1940s. A recent resurgence of use has occurred secondary to new problems with antibiotic resistance, especially in the setting of complex wounds.¹ Honey has many physical characteristics that allow for effective autolytic wound debridement. Its anti-inflammatory properties include modulation of immune cells, monocytes, and B and T lymphocytes as well as stimulation of the release of cytokines to promote healing.²

At Christiana Care Health System (Newark, DE; the institution in which this case series took place), there is no standard dressing choice for acute traumatic wound management. In light of this, the authors sought an optimal dressing for their patients who were too high risk for or did not wish to pursue operative debridement. Active Leptospermum honey (ALH; MEDIHONEY; Integra LifeSciences, Plainsboro, NJ) was selected for evaluation secondary to availability, low cost, and the properties of autolytic debridement, bacterial growth inhibition, anti-inflammatory mediation, and cytokine release.^1-4 The purpose of this article is to present a case series of 12 patients who underwent treatment with ALH as an alternative to surgery for dissimilar wounds.

A retrospective review of clinical experience, medical review, and photographic documentation was undertaken after receiving approval from Christiana Care Institutional Review Board (Newark, DE). All patient charts on the acute wound care service from 2012 to 2015 were reviewed. To be included, patients had to decline the recommendation of operative debridement or skin grafting, utilize ALH as an alternative to operative debridement, and have regular follow-up visits. Twelve patients who met these criteria were identified. Demographic information including age, sex, and medical comorbidities were collected. Wound measurements, descriptions, and photographic documentation at initial presentation and at subsequent follow-up were collected and reviewed to assess wound progression and healing (Table).

Case 1: traumatic right lower leg wound
A 100-year-old woman with medical comorbidities significant for prior cerebrovascular accident requiring dual antiplatelet therapy and increased pain sensitivity fell backward while trying to sit down, resulting in an injury to her right anterior tibia. On initial evaluation, her wound (measuring 4 cm x 3 cm x 2 cm) was irrigated with normal saline and debrided in the emergency department with loose approximation of the skin flap. The wound then was dressed with oxidized regenerated cellulose [ORC; PROMOGRAN PRISMA; Systagenix, an Acelity Company, Skipton, UK) and gauze.

The patient re-presented 2 days later with necrosis of the skin flap. This required bedside scalpel and gauze debridement but was limited secondary to pain as the patient also suffered from hypersensitivity pain disorder. She underwent a course of wet-to-moist dressings for 2 weeks. Operative debridement was recommended at that time secondary to the burden of eschar and slough, limited ability to perform bedside conservative debridement secondary to patient tolerance, and lack of improvement in the wound 4 weeks after injury. However, the patient was considered at high risk for sedation and was advised to continue her antiplatelet medications for the surgery. Her dressing regimen was changed to ALH gel covered with an occlusive film (Tegaderm; 3M, St Paul, MN) and changed every 3 days to promote autolytic debridement as intraoperative debridement was not an option for this patient.

At each subsequent follow-up, the wound had decreased in size, increased in percentage of granulation tissue, and decreased in amount of slough and/or eschar. The patient’s wound healed with minimal conservative bedside scalpel and gauze debridement and ALH 10 weeks after her injury.

Case 2: posterior tibial wound
A 40-year-old man with no medical comorbidities presented with trauma activation secondary to a motorcycle collision. He was found to have a large, irregular-shaped, gaping anterolateral left lower extremity (LLE) laceration that exposed the underlying muscle, fascia, and subcutaneous tissues. His wound was irrigated copiously with normal saline in the trauma bay with removal of any gross debris and was closed in 2 layers, the laceration repair totaling > 30 cm (Figure 1). He was discharged home that night with instructions to clean the wound twice daily with soap and water and to follow up with the acute wound care clinic in 1 to 2 weeks.

At his 2-week follow-up appointment, his sutures were removed with a residual wound measurement of 4 cm x 4 cm. The wound demonstrated significant eschar, slough, murky drainage, and swelling. He was sent home on antibiotic therapy and bacitracin for local wound care with follow-up visit 1 week later.

At the 1-week follow-up (3 weeks post injury), worsening eschar and slough were noted. At that time, operative debridement was considered given the volume of eschar, slough, and overlying infected appearance of the wound, but the clinicians proceeded as per patient request with conservative bedside scalpel and gauze debridement in their office and placement of the ALH gel/film dressing.

The wound improved with decreasing necrotic tissue and new healthy tissue growth at each weekly follow-up appointment. Initially, ALH dressing changes occurred daily, but with the improved appearance and decreased exudate, this was transitioned to every 3 days. About 10 weeks after his initial injury, his wound healed without any operative intervention.

Case 3: LLE injury
A 65-year-old woman with atrial fibrillation on warfarin anticoagulation therapy and a history of cerebrovascular accident, cardiac arrhythmia with pacemaker, and fibromyalgia presented with a LLE injury measuring 2.5 cm x 3.5 cm (Figure 2). On initial evaluation 1 week post injury (Figure 2A), she was found to have an elevated international normalized ratio (INR) of 6, indicating a propensity for bleeding, with an LLE hematoma and overlying cellulitis. Given her multiple comorbidities, she was at high risk for developing wound complications. After appropriate reversal of her coagulopathy, the hematoma was drained at bedside followed with a short course of wet-to-dry dressings to the area. Wound measurement at that time was 4 cm x 6 cm x 0.5 cm.

Further bedside scalpel and gauze debridement was performed to partially remove dark eschar, followed by an application of ALH gel and film dressings every 3 days. She was discharged home with an unfortunate lapse in her ALH therapy (lapse from post injury days 7-14).

At 2-week follow-up (Figure 2C), her wound demonstrated 90% eschar and a small hematoma. Operative intervention was considered at this time secondary to burden of necrotic tissue; however, the patient was at high risk for operative intervention secondary to her cerebrovascular and cardiovascular comorbidities and need for uninterrupted anticoagulation therapy. Conservative bedside scalpel and gauze debridement was performed with an application of ALH gel and film dressing. This was further complemented with noncontact low-frequency ultrasound therapy at her next follow-up appointment 1 week later.

Two months after her initial bedside debridement, her wound significantly improved with complete healing by 12 weeks.

Operative debridement has been the foundation of wound management, but with the increasing number of complex patients and wounds, alternative options need to be investigated. Active Leptospermum honey is a viable therapy for wound management in patients who have contraindications for operative debridement or request conservative management. However, operative debridement should remain a tenet of wound management in appropriate patients. In the present case series, the authors reported 12 patients who either were not operative candidates secondary to their medical comorbidities or did not wish to undergo operative debridement for personal reasons; all patients achieved wound closure with the assistance of ALH.

Medical-grade honey is gamma irradiated to allow for sterilization without loss of its antibacterial properties.⁵ Honey marketed for oral intake is heat treated to allow for safe ingestion, but in this process, the antibacterial effects of the honey are lost.⁵ The Unique Manuka Factor (UMF) is a rating scale for the antibacterial effects of honey.⁵ Medical-grade honeys have high UMF, indicating that even when diluted, medical-grade honeys maintain antibacterial properties.⁵

The high sugar content not only creates an osmotic gradient resulting in bacterial dehydration but also hinders bacterial growth.⁶ It further forms low levels of hydrogen peroxide that are toxic to bacteria but not to healthy tissue.⁶ This is very important in elderly and neonate populations, as both populations are immunocompromised to a varying degree, making them more susceptible to infection.

Second, ALH has anti-inflammatory properties. Although not completely understood, studies have demonstrated ALH stimulation of monocytes in cell culture resulting in the release of many cytokines involved in wound healing and regulation of the inflammatory cascade.² These properties have been reported² to decrease edema and pain while allowing increased blood flow to the area with the needed mediators for wound healing. Further, it has autolytic debridement properties stemming from activation of tissue proteases and the osmotic gradient created, which removes the wound of debris and slough.² These properties are significant if operative debridement is not undertaken. The alternative therapy needs to provide debridement properties and support wound healing.

In a case series by Blaser et al,⁷ the effects of medical-grade honey on wounds colonized or infected with Methicillin-resistant Staphylococcus aureus (MRSA) were investigated. Their case series looked at 7 patients with dissimilar wounds that were colonized or acutely infected with MRSA, confirmed by wound culture swab.⁷ All patients demonstrated negative wound swabs for MRSA at follow-up; however, the follow-up interval was not standardized, so they were unable to determine the length of time needed for eradication. The range of follow-up negative tests was 6 to 100 days.⁷ All patients went on to achieve wound closure, with only 1 patient requiring discontinuation of therapy secondary to pain but required no further debridement, which was thought to be attributed to the ALH. A study by Baghel et al⁶ compared the effects of honey versus silver sulfadiazine in burn wounds.⁶ All patients had wound cultures taken on admission and subsequently every 7 days until their wounds were healed.⁶ All patients with first-degree burns were treated with 5 days of intravenous (IV) antibiotics, while those with second-degree burns were given 10 days of IV antibiotics.⁶ The average duration of healing was significantly less in the honey group compared with the silver sulfadiazine, and ultimately, 81% of the wounds treated with honey went on to heal compared with 37% of the silver sulfadiazine.⁶ Further, patients in the honey group had negative wound cultures as early as 7 days, with all patients having sterile wounds by day 21; only 36.5% of the silver sulfadiazine wounds became sterile by day 21.⁶

Mohr et al⁹ presented 3 neonatal patients treated with ALH. In 1 case, they⁹ described a neonate with a complicated neonatal intensive care course including sepsis, vasopressor requirements, nutrition from hyperalimentation, and steroid therapy. The neonate developed ischemia of the left toes that was treated conservatively with ALH to heal the wound, thus preventing amputation.⁹ This case series demonstrated the difficulty of treating wounds in the neonate population and the need for consideration of alternative therapies for this patient population. Like neonatal patients, elderly patients present a challenge for wound healing and necessitate alternatives to aggressive operative debridement.

In the present case series, wound healing was facilitated by the autolytic debridement as well as antibacterial properties of ALH. Active Leptospermum honey is a viable option for wound management in patients with complex wounds, age-related clinical comorbidities precluding operative intervention, and patients desiring conservative management of their wounds. Randomized, controlled trials are needed to further investigate the properties of ALH in a controlled fashion, but given the many variables associated with patients and wounds, this is a challenge.

Authors: Jennifer Bayron, MD; Kathy Gallagher, DNP, APRN, FNP, FACCWS; and Luis Cardenas, DO, PhD

Affiliation: Christiana Care Health System, Newark, DE

Correspondence: Jennifer Bayron, MD, Christiana Care Health System, Surgery, 4755 Ogletown-Stanton Road, Suite 2E70-B, JHA Education Center, Newark, DE 19718; Jennifer.Bayron@christianacare.org

Disclosure: The authors disclose no financial or other conflicts of interest.